Isolated abnormal FEF75% detects unsuspected bronchiolar obstruction in CF children.

BACKGROUND: Physiologic detection of bronchiolar obstruction in children with cystic fibrosis (CF) may be clinically unsuspected because of normal routine spirometry despite bronchiectasis on lung CT. METHODS: Children from two accredited CF facilities had spirometry obtained every 3 months when clinically stable. Pre-bronchodilator maximum expiratory flow volume curves were retrospectively analyzed over 16 years to detect an isolated abnormal FEF75%, despite normal routine spirometry. RESULTS: At Miller Children's and Women's Hospital (MCWH), an abnormal FEF75% was initially detected in 26 CF children at age 7.5 ± 4 (SD) years despite normal routine spirometry initially. FEF75% remained an isolated abnormality for 2.5 ± 1.5 years after it was initially detected in these 26 CF children. At Cohen Children's Medical Center (CCMC), despite normal routine spirometry initially, abnormal FEF75% occurred in 13 children at age 11.7 ± 4.5 years, and abnormal FEF25-75% in 10 children at age 11.8 ± 5.3 years. CONCLUSIONS: FEF75% was most sensitive spirometric test for diagnosing both early and isolated progressive bronchiolar obstruction. Data from CCMC in older children demonstrated the simultaneous detection of abnormal FEF75% and FEF25-75% values consistent with greater bronchiolar obstruction when serial spirometry was initiated at an older age. IMPACT: There is very little published spirometric data regarding diagnosis of isolated small airways obstruction in CF children. FEF75% can easily detect unsuspected small airways obstruction in CF children with normal routine spirometry and bronchiectasis on lung CT and optimize targeted modulatory therapies.

Clinician Identification of Birth Asphyxia Using Intrapartum Cardiotocography Among Neonates With and Without Encephalopathy in New Zealand.

Importance: Despite improvements in antenatal care and increasing cesarean delivery rates, birth asphyxia leading to neonatal encephalopathy (NE) continues to contribute to neonatal death and long-term neurodevelopmental disability. Cardiotocography (CTG) has been used in labor for several decades to detect a stressed fetus so that delivery can be expedited and NE avoided. Objective: To investigate whether experienced clinicians can detect and respond to abnormal readings from CTGs during the penultimate hour before birth in infants with moderate to severe NE but no acute peripartum event. Design, Setting, and Participants: This case-control study included 10 practicing obstetricians and midwives at maternity hospitals in New Zealand. Participants, who were masked to the perinatal outcome, were asked to assess CTG tracings from 35 neonates with NE and evidence of birth hypoxia (ie, cases) and 105 neonates without NE or birth hypoxia (ie, controls), all of whom were born in 2010 to 2011. Data analysis was conducted from May to December 2017. Exposures: Brief clinical details and 1 hour of CTG tracings from the penultimate hour before birth were provided for each baby. Clinicians assessed the CTG tracings and recommended a plan. Main Outcomes and Measures: Intra-assessor and interassessor agreement on CTG findings and action plans as well as sensitivity (ie, detection of NE) and specificity (ie, ruling out those without NE) for the assessment of abnormal CTG readings leading to immediate action (ie, fetal blood sample or immediate delivery) were reported. Results: A total of 35 infants (mean [SD] gestational age, 40 [1.4] weeks; 16 [45.7%] cesarean deliveries) were designated cases, and 105 infants (mean [SD] gestational age, 39.4 [1.2] weeks; 22 [21.0%] cesarean deliveries) were designated controls. No infants had congenital anomalies. The mean (range) sensitivity for detection of abnormal CTG results and for recommending immediate action for all assessors was 75% (63%-91%) and 41% (23%-57%), respectively, with a mean (range) specificity of 67% (53%-77%) and 87% (65%-99%), respectively. A sensitivity analysis including only assessors with 80% or more interassessor agreement only differed from the main analysis by 6% or less (mean [range] sensitivity for detection, 76% [63%-91%]; sensitivity for action plan, 36% [25%-49%]; specificity for detection, 71% [53%-77%]; and specificity for action plan, 93% [88%-99%]). Conclusions and Relevance: Experienced clinicians detected 3 of 4 infants who were subsequently diagnosed with NE. Action to expedite delivery was recommended for more than 40% of infants with NE. These results indicate that CTG does not identify all infants at risk of NE, and that there is a need for further investment in new approaches to fetal surveillance in labor.

Contributory factors and potentially avoidable neonatal encephalopathy associated with acute peripartum events: An observational study.

BACKGROUND: In 25% of affected babies, neonatal encephalopathy results from acute peripartum events, but rigorous review of these cases for quality improvement is seldom reported. New Zealand has maintained a national database of all babies diagnosed with Sarnat moderate and severe neonatal encephalopathy since 2010 under the Perinatal and Maternal Mortality Review Committee. AIMS: To determine the rate of contributory factors, potentially avoidable mortality or morbidity, and to identify key areas for improvements to maternity and neonatal care among cases of neonatal encephalopathy following an acute peripartum event. MATERIALS AND METHODS: Sarnat moderate and severe cases identified from the national collection of neonatal encephalopathy with a history of an acute peripartum event were reviewed using a standardised independent multidisciplinary methodology and a tool for assessing contributory factors and potential avoidability, with the addition of a human factors lens. RESULTS: Forty-seven cases from 2013 to 2015 were reviewed. The most common acute peripartum events were placental abruption (12) and shoulder dystocia (11). Contributory factors were identified in 89%, and the severity of outcome was potentially avoidable in 66%. Key modifiable areas included dynamic risk assessment, preparedness for obstetric and neonatal emergencies, best practice for maternal and fetal surveillance in labour, and documentation. CONCLUSIONS: There is significant potential to improve quality and safety in acute peripartum care to reduce the risk of neonatal encephalopathy. Human factors were not well captured by the clinical notes or review tool. Attention to human factors by improved methodology can enhance review of neonatal encephalopathy.

Classification of causes and associated conditions for stillbirths and neonatal deaths.

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.

Rethinking placental pathology in the PSANZ classification of unexplained stillbirth at term.

BACKGROUND: Approximately 30 per cent of stillbirths are currently classified 'unexplained' using the Perinatal Society of Australia and New Zealand (PSANZ) classification system in New Zealand. This unexplained category includes deaths with placental pathology even though the importance of placental pathology and its causal relationship to stillbirth is well described. AIMS: To determine whether unexplained stillbirths in New Zealand classified using PSANZ criteria can be more usefully classified based on placental pathology. METHODS: Audit of the classification of cause of death among 'unexplained antepartum death' at term by perinatal pathologist review of postmortem and/or placental pathology reports using the current PSANZ Perinatal Death Classification (PDC)10 classification and a proposed 'significant placental pathology' subclassification. The main outcome measure was a change in cause of death from unexplained term stillbirth to an alternative PSANZ classification or to significant placental pathology subcategory. RESULTS: In total, 177 unexplained stillbirths with a postmortem and/or placental pathology report in New Zealand between 2007 and 2013 inclusive were reviewed. Twenty-three cases (13%) had significant placental pathology that could have been a direct cause of the stillbirth. A further seven cases (4%) were misclassified and could be better classified within another PDC category. CONCLUSIONS: A classification system incorporating placental pathologies which are recognised by the current literature to be causative of stillbirth would better describe stillbirths at term in New Zealand. This would benefit parental counselling and follow-up in subsequent pregnancies. A standard approach to reporting placental pathology would benefit clinicians. Education on placental pathology for clinicians working with parents experiencing stillbirth and multidisciplinary approach to classification is also recommended.

Validation of local review for the identification of contributory factors and potentially avoidable perinatal deaths.

BACKGROUND: Reporting on perinatal mortality commenced 2006 in New Zealand through the Perinatal and Maternal Mortality Review Committee (PMMRC). Following review of international models, a process was developed for use in local review to identify contributory factors and potentially avoidable perinatal deaths. Local review of 720 perinatal deaths in 2009 found contributory factors in 24% of deaths and 14% to be potentially avoidable. AIMS: To validate the process of local review for identification of contributory factors and potentially avoidable perinatal deaths. MATERIAL AND METHODS: Records of 48 perinatal deaths were reviewed by an independent multidisciplinary panel using the same methodology as local review to determine agreement between local and independent review for identification of contributory factors and potentially avoidable perinatal death. RESULTS: Independent review found contributory factors in 54% of deaths compared to 40% by local review. Independent review identified eight deaths and local review identified one death with contributory factors not identified by the other review. Kappa statistic for agreement for identifying contributory factors was substantial [0.63 (0.42, 0.84)]. Independent review found 42% of deaths potentially avoidable compared to 23% by local review. Independent review identified 10 deaths and local review identified one death not identified by the other review. Kappa statistic for agreement for identifying potentially avoidable deaths was moderate [0.50 (0.26, 0.73)]. CONCLUSIONS: This study provides validation of local review for identification of contributory factors in perinatal death. The higher proportion of potentially avoidable perinatal deaths identified by independent review compared to local review requires further exploration.

Contributory factors and potentially avoidable neonatal encephalopathy associated with perinatal asphyxia.

BACKGROUND: The recently published monograph, Neonatal encephalopathy and neurologic outcome, from the American College of Obstetricians and Gynecologists calls for a root cause analysis to identify components of care that contributed to cases of neonatal encephalopathy to design better practices, surveillance mechanisms, and systems. All cases of infants born in New Zealand with moderate and severe neonatal encephalopathy were reported to the New Zealand Perinatal and Maternal Mortality Review Committee from 2010. A national clinical review of these individual cases has not previously been undertaken. OBJECTIVES: The objective of the study was to undertake a multidisciplinary structured review of all cases of neonatal encephalopathy that arose following the onset of labor in the absence of acute peripartum events in 2010-2011 to determine the frequency of contributory factors, the proportion of potentially avoidable morbidity and mortality and to identify themes for quality improvement. STUDY DESIGN: National identification of, and collection of clinical records on, cases of moderate or severe neonatal encephalopathy occurring after the onset of labor in the absence of an acute peripartum event, excluding those with normal gases and Apgar scores at 1 minute, among all cases of moderate and severe neonatal encephalopathy at term in New Zealand in 2010-2011 was undertaken. Cases were included if they had abnormal gases as defined by any of pH of ≤ 7.2, base excess of ≤ -10, or lactate of ≥ 6 or if there were no cord gases, an Apgar score at 1 minute of ≤ 7. A clinical case review was undertaken by a multidisciplinary team using a structured tool to record contributory factors (organization and/or management, personnel, and barriers to access and/or engagement with care), potentially avoidable morbidity and mortality and to identify themes to guide quality improvement. RESULTS: Eighty-three babies fulfilled the inclusion criteria for the review, 56 moderate (67%) and 27 severe (33%), 21 (25%) of whom were deceased prior to hospital discharge. Eighty-four percent of 64 babies with cord gas results had one of pH of ≤ 7.0, base excess of ≤ -12, or lactate of ≥ 6; and 42% (8 of 19) without cord gases had 5 minute Apgar scores < 5. Excluding 5 babies who died within a day of birth, all but 1 baby were admitted to a neonatal unit within 1 day of birth. Contributory factors were identified in 84% of 83 cases, most commonly personnel factors (76%). Fifty-five percent of cases with morbidity or mortality were considered to be potentially avoidable, and 52% of cases were considered potentially avoidable because of personnel factors. The most frequently identified theme related to the use and interpretation of cardiotocography in labor. CONCLUSION: A multidisciplinary case review of neonatal encephalopathy following apparently uncomplicated labor identified a high rate of potentially avoidable morbidity and mortality and issues amenable to quality improvement such as multidisciplinary training of staff in fetal surveillance in labor.

Under-reporting of maternal and perinatal adverse events in New Zealand.

OBJECTIVES: To determine the proportion of maternal and perinatal mortality and morbidity cases, identified by the Perinatal and Maternal Mortality Review Committee (PMMRC), that are also reported within the annual serious adverse events (SAEs) reports published by the Health Quality and Safety Commission (HQSC). SETTING: Nationally collated data from the PMMRC and HQSC, New Zealand. PARTICIPANTS: Analysis of maternal and perinatal mortality and morbidity data 2009-2012. INTERVENTIONS: Every SAE report published by the HQSC from 2009 to 2012 was scrutinised for maternal and perinatal cases using the case history provided by district health boards (DHB). Further detail of each case was requested from each DHB to establish whether they had been identified as maternal or perinatal mortalities or morbidities by the PMMRC. PRIMARY OUTCOME MEASURE: The proportion of maternal and perinatal mortality and morbidity cases identified by HQSC SAE reports, compared with PMMRC reporting. RESULTS: 58 maternal and perinatal SAEs were identified from the SAE reports 2009-2012. Of these, 50 fit under the PMMRC reporting definitions, all of which were also reported by the PMMRC. In the same time frame, the PMMRC captured 536 potentially avoidable maternal and perinatal mortalities and morbidities that fitted the HQSC SAE definition. Fewer than 9% of maternal and perinatal SAEs are captured by the HQSC SAE reporting process. CONCLUSIONS: The rate of maternal and perinatal adverse event reporting to the HQSC is low and not improving annually, compared with PMMRC reporting of eligible events. This is of concern as these events may not be adequately reviewed locally, and because the SAE report is considered a measure of quality by the DHBs and the HQSC. Currently, the reporting of SAEs to the HQSC cannot be considered a reliable way to monitor or improve the quality of maternity services provided in New Zealand.

Early detection of severe maternal morbidity: a retrospective assessment of the role of an Early Warning Score System.

BACKGROUND: The Early Warning Scoring (EWS) surveillance system is used to identify deteriorating patients and enable appropriate staff to be called promptly. However, there is a lack of evidence that EWS surveillance systems lead to a reduction in severe morbidity. AIMS: To determine whether as EWS may have improved the detection of severe maternal morbidity or lessened the severity of illness among women with severe morbidity at a large tertiary maternity unit at Auckland City Hospital (ACH), New Zealand. METHODS: Admissions to intensive care, cardiothoracic and vascular intensive care, or an obstetric high-dependency unit (HDU) were identified from clinical and hospital administrative databases. Case reviews and transcribed observation charts were presented to a multidisciplinary review group who, through group consensus, determined whether an EWS might have hastened recognition and/or escalation and effective treatment. RESULTS: The multidisciplinary review team determined that an EWS might have reduced the seriousness of maternal morbidity in five cases (7.6%), including three admissions for obstetric sepsis to intensive care unit and two to obstetric HDU for post-partum haemorrhage. No patient had a complete set of respiratory rate, heart rate, blood pressure and temperature recordings at every time period. CONCLUSIONS: These findings have been used to support introduction of an EWS to the maternity unit at ACH.

Can we improve the prevention and detection of congenital abnormalities? An audit of early pregnancy care in New Zealand.

AIM: To determine whether there were "quality gaps" in the provision of care during pregnancies that resulted in a perinatal death due to congenital abnormality. METHOD: Perinatal deaths from congenital cardiovascular, central nervous system or chromosomal abnormality in 2010 were identified retrospectively. Data were extracted by retrospective clinical note review and obtained by independent review of ultrasound scans. RESULTS: There were 137 perinatal deaths due to a congenital cardiovascular (35), central nervous system (29) or chromosomal abnormality (73). First contact with a health professional during pregnancy was predominantly with a general practitioner. First contact occurred within 14 weeks in 85% of pregnancies and there was often a significant delay before booking. Folate supplements were taken by 7% pre-conceptually and 54% of women in the antenatal period. There were 20 perinatal deaths from neural tube defects that could potentially have been prevented through the use of pre-conceptual folate. Antenatal screening was offered to 75% of the women who presented prior to 20 weeks and 84% of these undertook at least one of the available antenatal screening tests. Review of ultrasound images found five abnormalities could have been detected earlier. CONCLUSION: Delay in booking or failure to offer screening early were the most common reasons for delay in diagnosis of screen detectable abnormalities. The preventative value and timing of (pre-conceptual) folate needs emphasis.

Review of contributory factors in maternity admissions to intensive care at a New Zealand tertiary hospital.

OBJECTIVE: The purpose of this study was to identify factors that contributed to severe maternal morbidity, defined by admission of pregnant women and women in the postpartum period to the intensive care unit (ICU) from 2010-2011 at Auckland City Hospital (ACH), a tertiary hospital that delivers 7500 women/year, and to determine potentially avoidable morbidity with the use of local multidisciplinary review. STUDY DESIGN: All admissions of pregnant women and women in the postpartum period (to 6 weeks) to the ICU at ACH from 2010-2011 were identified from hospital databases. Case notes were summarized and discussed by a multidisciplinary team. The presence of contributory factors and potentially avoidable morbidity were determined by consensus with a tool that was developed by the New Zealand Perinatal and Maternal Mortality Review Committee for the review of maternal and perinatal deaths. Specific recommendations for clinical management were identified by the multidisciplinary group. RESULTS: Nine pregnant women and 33 women in the postpartum period were admitted to the ICU from 2010-2011. Contributory factors were identified in 30 cases (71%); 20 cases (48%) were considered to be potentially avoidable; personnel factors were the most commonly identified avoidable causes. Specific recommendations that resulted from the study included the need for the development of guidelines for puerperal sepsis, improved planning for women at known risk of postpartum hemorrhage, enhanced supervision of junior staff, and enhanced communication through multidisciplinary meetings. CONCLUSION: Forty-eight percent of severe maternal morbidity, which was defined as admission to the ICU at ACH from 2010-2011, was considered to be potentially avoidable by a local multidisciplinary review team; priorities were identified for improvement of local maternity services.

Beyond the numbers: classifying contributory factors and potentially avoidable maternal deaths in New Zealand, 2006-2009.

OBJECTIVE: We sought to describe a new classification system for contributory factors in, and potential avoidability of, maternal deaths and to determine the contributory factors and potential avoidability among 4 years of maternal deaths in New Zealand. STUDY DESIGN: A new classification system for reporting contributory factors in all maternal deaths was developed from previous tools and applied to all maternal deaths in New Zealand from 2006 through 2009. RESULTS: There were 49 deaths and the maternal mortality ratio was 19.2/100,000 maternities. Contributory factors were identified in 55% of cases. An expert panel identified 35% of maternal deaths as potentially avoidable. In cases where potential avoidability was determined, there were nearly always 2 or 3 domains where contributory factors were identified. CONCLUSION: Almost one third of maternal deaths in New Zealand can be considered to be potentially avoidable. This methodology has the potential to identify areas for improvement in the quality of maternity care.